Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

A nurse sees a nursing assistant leave a confused patient’s bed in the highest position after care. What should the nurse do?

1. ALower the bed now and remind the assistant why it matters
2. BLeave it because the patient is asleep
3. CWrite it in the assistant’s yearly review only
4. DAsk the family to lower the bed when they next visit

A patient at 32 weeks of pregnancy feels dizzy and faint while lying flat on her back. What should the nurse do first?

1. ASit her upright with her head between her knees
2. BRaise her legs while she stays on her back
3. CGive her a sugary drink and keep her flat
4. DTurn her onto her left side

Pernyataan manakah tentang penggunaan sekatan fizikal yang betul?

1. ASekatan boleh digunakan setiap kali unit kekurangan kakitangan kejururawatan
2. BAlternatif didahulukan, dan arahan yang terhad masa diperlukan
3. CArahan sekatan berterusan mengikut keperluan ialah amalan yang baik
4. DSekatan disemak sekali pada akhir setiap syif

A patient’s allergy band says “penicillin”, and an order has been written for amoxicillin. What should the nurse do?

1. AAsk the patient whether they would like to take it anyway
2. BGive an antihistamine first and then the drug
3. CHold the drug and contact the prescriber
4. DGive the drug and watch the patient closely

A patient on a heparin infusion has an aPTT below the target range on the protocol. What should the nurse do?

1. AStop the infusion and give protamine sulfate as quickly as possible
2. BContinue the same rate and recheck the aPTT in a few days
3. CAdjust the rate as the protocol directs and recheck as scheduled
4. DSwitch the infusion to oral warfarin without a prescription

A patient with heavy alcohol use and a poor diet has a hemoglobin of 10.1 g/dL (101 g/L), an MCV of 110 fL and a low red cell folate. Which explanation fits best?

1. AIron deficiency from slow, chronic bleeding in the gut
2. BThalassemia trait inherited from one of the parents
3. CFolate deficiency, made worse by a direct alcohol effect
4. DAnemia caused by long-standing chronic kidney disease

During a red cell transfusion, when are serious acute reactions most likely to start?

1. AAbout 24 hours later
2. BIn the first 15 minutes
3. CAfter the third unit only
4. DOnly after the unit has finished

Which finding suggests hypocalcaemia?

1. ASpasm of the hand when a blood pressure cuff is inflated on the arm
2. BSevere thirst with a large urine output and constipation
3. CA flapping tremor of the outstretched hands
4. DA slow, irregular pulse with nausea and yellow-tinged vision

Why is a raised serum lactate concerning in a patient with shock?

1. AIt means the kidneys are working harder than normal to clear fluid
2. BIt suggests tissues are short of oxygen and using anaerobic metabolism
3. CIt shows only that the patient has eaten a large meal in the past hour
4. DIt confirms a bacterial infection is present

Seorang berumur 82 tahun dengan pneumonia komuniti baru mengalami kekeliruan, dengan RR 32/min, TD 88/52 mmHg dan urea 9 mmol/L. Apakah yang ditunjukkan oleh ini?

1. ASkor CURB-65 sebanyak 3: kemasukan rutin ke wad am sahaja
2. BSkor CURB-65 sebanyak 1: sesuai untuk antibiotik oral di rumah
3. CSkor CURB-65 sebanyak 5: risiko tinggi yang memerlukan semakan pegawai kanan segera
4. DTindak balas normal terhadap jangkitan pada warga emas

An 80-year-old with angina is diagnosed with hypothyroidism. How is levothyroxine usually started?

1. AOnly after the angina has been cured
2. BAt a full dose from the first day
3. CAs a single large weekly injection
4. DAt a low dose, increased slowly

A patient with long-standing diabetes suddenly has many new floaters and painless loss of vision in one eye. What is most likely, and what is needed?

1. AA bleed into the eye from retinopathy, needing urgent review
2. BDry eyes, needing lubricating drops
3. CNormal ageing of the lens, needing new glasses
4. DA migraine aura, needing pain relief

Which treatment often relieves pain from a bone metastasis?

1. APalliative radiotherapy to the area
2. BIron supplements by mouth for several months
3. CComplete bed rest for a month
4. DA diet low in calcium and vitamin D

A patient with diabetes on continuous enteral feeding and an insulin regimen has the feed stopped for a procedure. What is the main concern?

1. AHyperglycaemia because the stomach is empty
2. BRefeeding syndrome from too much glucose
3. CDiarrhoea from stopping the feed suddenly
4. DHypoglycaemia if insulin continues without the feed